B1 Flashcards
List the clinical features ( S&S) of pneumonia ( at least 4 )
Symptoms
- Hyperpyrexia ( > 38C)
- Pleuritic chest pain
- Dyspnoea
- Haemoptysis
- Cough with mucopurulent sputum : Rusty sputum - pneumococcus
- Loss of appetite
- Fatigue , malaise , muscle aches
- Sinusitis , URI ( Legionella )
- Nausea and vomiting
- Diarrhoea ( Legionella )
- Chills and rigors
Signs
- Fever
- Hypotension
- Tachypnoea
- Confusion
- Tachycardia , bradycardia
- Central cyanosis
- Use of accessory respiratory muscles : Scalene muscle , SCM , Pectoralis major , trapezius , external, intercostal
-Signs of consolidation : Diminished chest expansion , Dull percussion note , Increased tactile vocal fremitus / vocal resonance , vocal, Bronchial breathing , Pleural rub
- Signs of pleural effusion : Stony dullness on percussion
- Herpes labialise : In pneumococcal infections
List lab investigations for pneumonia
1) Complete blood count ( CBC ) with differential leukocyte count
- to check MCV , MCH , MCHC , leukocytosis etc
2) Blood culture and sensitivity
- check bactermia
- done prior to antibiotics administration
3) Chest X - ray
- shows consolidation , pleural effusion , collapse , hilar lymphadenopathy
4) Sputum tests
- Gram stains
- Culture of colonies
5) Pulse oximetry
- see O2 saturation
6) Bronchoscopy
7) PCR
8) Serology
9) CT scan
10) ABG determination
- see pH of blood , paO2 , etc
State some complication of pneumonia
1) Lung abscess / empyema ( abscess in pleural space )
2) Septicemia , bacteremia
- leads to meningitis , endocarditis , septic arthritis , multi-organ failure
3) Difficulty breathing and ARDS
4) Collapse of the affected lobe / segment
5)Circulatory and respiratory failure -> shock
6) Thromboembolic disease
The mnemonic (…………) can be used as prognostic marker for community-acquired pneumonia
- CURB-65
C - Confusion
U - serum urea <7mmol /L
R - respiratory rate > 30 / min
B - diastolic BP< 60mmHg
65 - > 65 years of age
State some predisposing factor to pneumonia
1) Elderly
2) Infants
3)Immunocompromised / immunosuppressed
4) Cigarette smokers
5) Alcoholics
- via vomit aspiration
6) COPD , asthmatics , CF , bronchiectasis
7) Dysphagic people
- stroke , dementia or other neurologic conditions
8) Heart disease , liver cirrhosis , diabetes
9) ICU patients
10 ) Nursing home patients
11) IV drug users : Staph .aureus infection
COPD is characterised by persistent airflow limitation, usually progressive & not fully reversible with an enhanced chronic inflammatory response in the airways & lung in response to noxious particles and gases.
It includes ( ………… ) & ( ………….. )
COPD is characterised by persistent airflow limitation, usually progressive & not fully reversible with an enhanced chronic inflammatory response in the airways & lung in response to noxious particles and gases.
It includes ( chronic bronchitis ) & ( emphysema )
Chronic bronchitis is defined as a ( …………………………………… )
Emphysema is the ( …………………………………………………. )
Chronic bronchitis is defined as a ( chronic , productive cough on most days for 3 months per year for at least 2 successive years )
Emphysema is the ( abnormal & permanent enlargement of airways distal to the terminal bronchioles that is accompanied by destruction of the airspace walls )
State the etiological factors of COPD
1) Smoking , second hand smoking & air pollution
2) Occupational hazards : ( dust , silica , chemical fumes )
3) Low birth weight
4) Bronchial hyper-responsiveness
5) Alpha- antitrypsin-1 deficiency ( elastase inhibitor , elastase destroys elastin in RT )
Describe the clinical features of COPD
1) Chronic productive cough
2) Difficultly breathing / exerted dyspnoea
- progressive dyspnoea : chronic bronchitis
- Constant dyspnoea : emphysema
3) Cyanosis
4) Chronic chest infections
5) Weight loss , tiredness
6 ) Pedal edema
- If Cor pulmonare occurs
7) Barrel- chest
- chest wall in AP plane increase in size
8) Expiratory pursed-lip breathing
9) Signs of CO2 retention
- flapping tremors ( asterixis )
- bonding pulse
- obtundation ( less than full alertness )
10) Signs of rt heart failure
- pedal edema
- ascites
- hepatomegaly
- JVP
11) Resonant percussion note
12 Crackles at lung bass
Describe the investigation of COPD
1) Spirometry
- FEV1 <80 % and FEV1/FVC <70% strongly suggest COPD
2) CXR
- shows bullae ( large areas with absence of lung markings )
- hypertranslucent lung field & flattened diaphragm
- chest shows hyperexpansion
3) Arterial blood gas analysis
- shows hypoxia and hypercapnia
4) Bronchiodilator trial
- after administering B2 agonist , if spirometry shows > 15% improvement in FRV1 -> bronchial asthma
- if < 15% improvement -> COPD
5) Culture & sensitivity of sputum
6) AAT deficiency screening
- done in young pt . with family history
Describe the treatment of COPD
1) Long term oxygen therapy (LTOT )
2) Smoking cessation
3) Bronchodilators
4) Oral corticosteroids
- to decrease freq. of acute exacerbation
- chronic use not recommended
5) Antibiotics is superadded infection occurs
6) Pulmonary rehab
7) Surgery
- lung reduction , transplant
State precipitating factors of asthma
A) Genetics : play more of a role in childhood asthma
B) Enviromental : pet dander , pollen m cigarette smoke , fungi , stress
- plays more of a role in adults / elderly asthma
C) Medicine
- B-blockers cause bronchospasm by inhibiting B2 receptors
- NSAIDs inhibit COX , diverting arachidonic acid production to LOX pathway , producing asthmogenic leukotriene
- oral contraceptives , cholinergic agents
D) Latex allergy
State the clinical features of asthma
Symptoms
1) Recurrent episodes of wheezing
2) Breathlessness
3) Chest tightness
4) Cough
5) Diurnal pattern
- symptoms & lung function worse in early morning
Signs
1) Tachycardia
2) Tachypnoea
3) Use of accessory respiratory muscle
4) Hyper-inflated chest
5) Hyper-resonant percussion
6) Breath sounds ( harsh vesicular breathing with prolonged expiration )
7) wheeze
8) Eosinophilia
Describe the investigation of asthma
1) Pulmonary function test
2) Peak expiratory flow rate
- measured using a peak flow meter which measure the max velocity of air expelled by an individual
- shows lower than normal value
3) Spirometry
- FEV1 <80%
- FEV1 / FVC <70%
- Following administration of bronchodilator , an improvement of at least 15% is diagnostic of bronchial asthma
4) CXR
- normal , but may show hyper inflated chest
5) Sputum differential eosinophil count>2%
6) CBC
- Shows eosinophilia
7) ABG analysis
Describe the management of asthma
1) Give O2
2) Minimize exposure of allergens
3) Cease smoking
4) Step-wise smoking
Step 1 : SABA ( salbutamol , terbutaline )
Step 2 : SABA + low dose ICS ( beclomethasone , budesonide , fluticasone )
Step 3 : SABA + LABA ( salmeterol ) + low dose ICS
Step 4 : SABA + LABA + high dose ICS / theophylline / LT antagonist
Step 5 : SABA + LABA + high dose ICS+ OCS
Describe the Pathogenesis of tuberculosis
- infection through inhalation of aerosolised droplet nuclei containing Mycobacterium tuberculosis or ingesting non sterilised milk (M. Bovis )
- m/o lodges into the alveoli
- leads to recruitment of macrophages & lymphocytes
- Macrophages transform into epitheloid cells and Langhans cell , forming a tuberculous granuloma
- granulomas aggregate to form Ghon focus in the periphery of the lung
- the primary complex get encased in a fibrous capsule which limits spread of bacilli ( latent TB)
- the Ghon’s complex may also undergo fibrosis or calcification & form Ranke complex
- if bacilli managed to spread hematogenously -> dormancy in other organs
Describe the clinical features of tuberculosis
Symptoms
- haemoptysis
- chronic cough
- fever and chills
- weight loss and weakness ( consumption )
- dyspnoea
- pleuritic chest pain
- nights sweats
Signs
- lymphadenopathy
- post - tussive crackles
- fever
- signs of consolidation
- unresolved pneumonia
- pneumothorax
- pleural effusion
Ghon’s focus is seen in ( ……………… ) and located at the ( ……………….. )
Simon focus is seen in ( ………………… ) and located at the (…………………. )
Ghon’s focus is seen in ( primary TB) and located at the ( middle or lower lobes )
Simon focus is seen in ( secondary TB ) and located at the ( apex of upper lobes as this is where there is highest concentration of O2 and where aerobic bacteria can thrive )
Describe the management of TB
Intensive phase ( HRZEP)
- take drugs daily or 3 x per week for 2 mths
- isoniazid 300 mg + rifampin 450mg + pyrazinamide 1500 mg + ethambutol 800 mg + pyridoxine 10mg
Continuous phase ( HRP)
- take drugs daily / 3 x weekly for 4 mths
- isoniazids 300 mg + rifampin 450mg + pyridoxine 10mg
Pott’s disease typically affects the ( …………………………… )
Pott’s disease typically affects the ( thoracic and lumbrosacral spine , knees and hips )
Describe the manifestation of TB in oral cavity
- appears as Stellate ulcers on dorsum of tongue
- also include palate , lips , buccal mucosa , gingiva , palatine tonsils , floor of mouth
-ulcers may present as non-healing ulcers or long duration , painless ulcers
- cervical lymphadenopathy ( matted lymph nodes ) + draining sinus
State some common causes of pleural effusion ( Transudative , exudative types )
Transudative ( protein <30g/L )
I) Congestive heart failure
II) Hypoproteinemia ( nephrotic syndrome , liver cirrhosis , malnutrition )
III) myxedema
IV) pericardial disease
Exudative ( protein >30g/L )
I) Tuberculosis
II) Malignancy
III) Acute rheumatic fever
IV) Pneumonia
V) pulmonary embolism
VI) SLE
VII) Uremia
VII) pancreatitis
IX) hemothorax , chylothorax
X)Meig’s syndrome
State the clinical feature ( S&S ) of pleural effusion
Symptoms
- dyspnoea
- cough with sputum
- pleuritic chest pain
- Hemoptysis
- fever
- weight loss
- trauma
- history of cancer , cardiac surgery and other symptoms related to the underlying cause
Signs
- blunting of costophrenic angle on CXR
- asymmetric chest expansion ( diminished on affected side )
- tracheal deviation to opposite side
- egophony above the level of pleural effusion
- stony dullness on percussion
- absent tactile fremitus
- decreased / absent breath sounds
- localised pleural friction rub
- raised JVP
- ascites
- peripheral edema
- unilateral leg swelling
- Tachypnoea
( ……………….. ) on percussion is a characteristic finding of pleural effusion , as well as ( …………………. ) on chest X-ray.
( Stony dullness ) on percussion is a characteristic finding of pleural effusion , as well as ( blunting of the costophrenic angle ) on chest X-ray.
Inspection - Tachypnoea
Palpatation- reduce expansion on R
- Trachea and apex may be moved to L
Percussion - stony dull
- R mid and lower zones
Auscultation - absent breath sounds ash vocal resonance R base
- Bronchial breathing or crackles above effusion
Describe the management of pleural effusion
1) Aspiration of pleural fluids ( thoracentesis )
- done to alleviate dyspnoea
2) Treat the underlying cause
The commonest cancer in men ( ……………… )
The commonest cancer in women is ( ……………… ) with ( ………………… ) being second
The commonest cancer in men ( lung cancer )
The commonest cancer in women is ( breast cancer ) with ( lung cancer ) being second
The common sites of metastasis for lung cancer are :
Liver - most common
Adrenals
Brain
Bone
Kidney
Metastasis of kidney cancer to the lungs present itself as ( …………………….. )
Metastasis of kidney cancer to the lungs present itself as ( “cannon ball” lesion / cannon ball metastasis)
State some symptoms of bronchiogenic carcinoma / lung cancer
1) Due to primary effect of tumor
- dyspnoea
- cough with streaks of blood in sputum
- pleuritic chest pain
- pleuritic effusion
- wheezing
- fever
2) Due to invasion into thorax
- dysphagia ( compression on oesophagus )
- dysphonia / hoarseness ( compression of laryngeal nerves )
- chest pain
- SVC syndrome
3) Due to metastasis to distant sites
-lymphadenopathy
- bone pain
- jaundice
- kidney failure
- neurological deficits ( seizures , dizziness , headaches )
4) systemic symptoms
- paraneoplastic syndrome — Cushing’s , hypercalcemia
- anorexia , weight loss , weakness
- clubbing of finger
5) Horner’ syndrome
Lung cancer can be divided into 2 :
( …………………..) & (……………………… )
( …………………… ) can be further divided into 3 types ( ……………………………………… )
( ………………………… ) occurs more frequently than ( …………………… ) and they grow fairly slowly , compared to ( ………………. ) which grow faster but occur less often.
Lung cancer can be divided into 2 :
( small cell lung cancer ( SCLC) ) & ( non- small cell lung cancer ( NSCLC) )
( Non- small cell lung cancer ) can be further divided into 3 types ( adenocarcinoma , large cell carcinoma and squamous cell carcinoma )
( Non - small cell lung cancers) occurs more frequently than ( small cell lung cancers) and they grow fairly slowly , compared to ( SCLCs ) which grow faster but occur less often.
In tuberculous lymphadenitis , the ( ……………………….. ) group of lymph nodes become enlarged and matted.
It can lead to a ( …………………. ) abscess and sinus formation
In tuberculous lymphadenitis , the ( supraclavicular and posterior cervical ) group of lymph nodes become enlarged and matted.
It can lead to a ( collar stud) abscess and sinus formation
(……………………..) is a complex agent of opportunistic TB infection
( M . Avium complex ) is a complex agent of opportunistic TB infection
Describe the Jone’s criteria of acute rheumatic fever
JONES CRITERIA
Major Manifestation
- Carditis ( friction rub , murmur , cardiomegaly , CHF )
- Arthritis ( migratory polyarthritis , swollen , red , tender )
- Chorea ( this describe inflammation of the central nervous system )
- Subcutaneous nodules ( lumps under the skin )
- Erythema marginatum ( rash )
Minor manifestation
- Clinical : Fever , Arthralgia , History of rheumatic fever or rheumatic heart disease
- Laboratory : ESR & C -reactive proteins raised , leukocytosis
: Characteristic ECG changes - ( Prolonged P-R interval
Diagnosis is made when :
I) 2 major criteria is met
II) 1 major + 2 minor + history of strep. Infection
Acute rheumatic fever usually affects children and young adults b/w the age of ( ………………… ) with evidence of preceding ( ………………… ) pharyngitis.
Acute rheumatic fever usually affects children and young adults b/w the age of ( 5 - 15 years ) with evidence of preceding ( group A streptococcal ) pharyngitis.
In acute rheumatic fever , ( …………….. ) can be given to relieve the symptoms of arthritis rapidly , and a response within 24hrs helps to confirm the diagnosis.
In acute rheumatic fever , ( aspirin ) can be given to relieve the symptoms of arthritis rapidly , and a response within 24hrs helps to confirm the diagnosis.
Elaborate the lab diagnosis of acute rheumatic fever
-WBC count and ESR is elevated
- Anti Streptolysin- O titer is elevated in 95 of patients -> 200 units in adults and > 300 units in children.
- C -reactive protein is positive
- Cardiac enzymes levels may increase in severe carditis ( These include the creative kinase ( CK ) & the proteins troponin I ( Tnl ) and troponin T ( TNT ) are linked with injury of the heart muscle.
- Throat cultures continue to show presence of GABS ( group A beta haemolytic streptococci ) ; however they usually occur in small number. Isolating them is difficult.
Describe the treatment of ARF
1) Bed rest until inflammation subsides
2) Antibiotic therapy
- IM benzathine penicilin ( 1.2m units ) every 3-4 wks
- Oral penicillin ( 250mg ) 4x daily for 10 days
- erythromycin or sulfadiazine if allergic to penicillin
3) Anti-inflammatory
- aspirin
- corticosteroids
Describe the long term prophylaxis of ARF :
1) In RF w/o carditis
2) In RF w/ carditis
3) In RF + carditis + valvular disease
Benzathine penicillin ( 1.2 m units ) every 3-4 wks IM
Or
Oral penicillin 250mg 2x/day
If allergic - erythromycin 250 mg 2x / day orally
1) Prophylaxis should be done for 5 years or until 21 yrs of age ( whichever is longer )
2) 10 years or into adulthood
3) 10 years since last episode or until 40 y of age ( sometimes lifelong )
Describe the diagnosis f infective endocarditis
Duke’s CRITERIA
Major Criteria
- 2 separate positive blood cultures with microorganism typical for infective endocarditis ( viridans streptococci , streptococcus bovis , HÁČEK group , staphylococcus aureus , enterococci )
- Echocardiographic evidence of endocardial involvement ( typical valvular lesion : vegetations , abscess or partial dehiscence of a prosthetic valve )
Minor criteria
- Predisposition : predisposing factor heart condition or IV drug use
- Temperature > 38C
- Vascular phenomena : major arterial emboli , septic pulmonary infarcts , mycotic intracranial haemorrhage , conjunctival haemorrhage , Janeway lesion
Immunological phenomena :glomerulonephrotis , Osler nodes , Roth spots , rheumatoid factor.
Microbiological evidence : positive blood culture but not meeting major criterion , or serologic evidence of active infection with organism consistent with infective endocarditis
^^ 2 major criteria , 1 major criteria and 3 minor criteria , 5 minor criteria
^^ Blood cultures should be taken at 3 separate times ( 30 m apart ) at 3 different sites , before commencement of antibiotic therapy
